Ventricular Rhythm Research Articles

Rationale and design of the French cohort of acute myocarditis diagnosed by cardiac magnetic resonance imaging (MyocarditIRM)

BackgroundAcute myocarditis usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favourable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders, and is considered the leading cause of sudden cardiac death in young, apparently healthy, adults. There are no specific recommendations for acute myocarditis diagnosis and management, only expert consensus, given the lack of large databases. AimThe main objective is to describe the contemporary presentation of acute myocarditis, its management and in-hospital outcomes. Secondary objectives are to investigate survival and event-free survival for up to 10years of follow-up, the determinants of prognosis, the modalities of treatment and follow-up and the gaps between expert consensus and real-life management. MethodsMyocarditIRM is a prospective multicentre cohort that enrolled 803 consecutive patients with acute myocarditis in 49 participating centres in France between 01 May 2016 and 28 February 2019. The diagnosis of acute myocarditis was acknowledged by cardiac magnetic resonance, using the Lake Louise Criteria. Exclusion criteria were age<18years, lack of health coverage, contraindication to cardiac magnetic resonance and refusal to participate. Detailed information was collected prospectively, starting at admission. Cardiac magnetic resonance imaging (diagnosis and follow-up) is analysed centrally by the certified core laboratory IHU ICAN. Ten years of follow-up for each patient is ensured by linking with the French National Health Database, and includes information on death, hospital admissions, major clinical events and drug consumption. ConclusionThis prospective cohort with long-term follow-up represents the largest database on acute myocarditis worldwide, and will improve knowledge about its presentation, management and outcomes.

Dynamics of heart rhythm disorders in combatants with acute myocarditis during a 6-month follow-up

The main factors of an unfavorable prognosis, are life-threatening heart rhythm disorders which determine the severity of the clinical course of myocarditis, in addition to impaired contractility and dilatation of the left ventricle (LV). The aim of the study was to assess the frequency and nature of arrhythmias and establish predictors of their long-term persistence, assess the severity of anxiety and depression, changes in heart rate variability in combatants on the background of changes in the structural and functional state of the left ventricle during a 6-month follow-up. The study included 52 male servicemen (combatants) with acute myocarditis (AM) with an average age of 33.4±2.5 years. All patients were assessed by Questionnaire according to the Hospital Anxiety and Depression Scale (HADS) and underwent 24 hour ECG monitoring, transthoracic echocardiography and cardiac magnetic resonance (CMR) with late enhancement using gadovist. At the onset of AM frequent supraventricular (30.7% of cases) and frequent ventricular (42.3% of cases) extrasystolic arrhythmia, as well as paroxysms of non-sustained ventricular tachycardia (26.9% of cases) on the background of heart rhythm variability disorders were recorded. After 6 months, there was an improvement in the structural and functional state of the heart, which was characterized by a decrease in dilatation and an improvement of LV systolic function, a decrease in the volume of the inflammatory lesion and the total number of affected LV segments revealed on cardiac MRI, which was associated with a decrease in the number of ventricular rhythm disorders and reduction of clinical manifestations of anxiety according to the HADS scale. The obtained data indicate that the persistence of supraventricular rhythm disorders is associated with the long-term presence of anxiety and low values of standard deviation of RR intervals (SDNN) and root mean square of successive differences between normal heartbeats (RMSSD). Also predictors of persistence of non-sustained ventricular tachycardia paroxysms were established – SDNN value ≤80.0 ms, LV end-diastolic volume index ≥95 ml/m2, total number of affected LV segments ≥6 segments, presence of delayed contrasting in ≥3 LV segments, pre­sence of ≥12 points on the HADS scale and predictors of atrial fibrillation – SDNN value ≤80.0 ms, RMSSD value ≤12.0 ms, total number of affected segments of LV≥6 seg. and ≥12 points on the HADS anxiety scale, determined at the onset of AM.

Complete Heart Block without Ventricular Escape Rhythm during Left Ventriculography

Complete Heart Block without Ventricular Escape Rhythm during Left Ventriculography

Brugada Phenocopy Induced by Electrocution: About a Case

Brugada Syndrome (BrS) is an inherited channelopathy secondary to a sodium channel defect (SCN5A), predisposing to ventricular arrhythmia and sudden death. The BrS electrocardiogram is often dynamic and can change from a type 1 to a type 2 pattern, passing through periods of normalisation. The term Brugada phenocopy was proposed by Pérez-Riera et al to describe the electrocardiographic aspect of Brugada observed in other situations, such as acute myocarditis, muscular dystrophy, or secondary to other agents such as electrocution, the taking of drugs such as psychotropic drugs, prolonged exposure to cold or carbon monoxide intoxication. Electrocution can cause serious cardiovascular damage, in particular malignant ventricular arrhythmias. We report the case of a 59-year-old patient who consulted the emergency ward for a cardiac work-up following electrocution. An ECG was performed, which revealed a transient Brugada type 1. In this case, we discuss the diagnostic procedures for this channelopathy, which carries a risk of ventricular rhythm disorders and sudden death, and the therapeutic management.

ST-elevation myocardial infarction in patients with type 2 diabetes mellitus. Influence of the SGLT2 inhibitor dapagliflozin

Background. Patients with type 2 diabetes mellitus (T2DM) have a 2-fold higher risk of deve­loping coronary heart disease and mortality than those without carbohydrate metabolism disturbances. The reason for such negative trends is the occurrence of metabolic stress due to hyperglycemia and insulin resistance, which causes disturbance in energy metabolism and ischemic damage to cardiomyocytes. The purpose of the study is to improve the effectiveness of rehabilitation treatment and assess the dynamics of quality of life in patients with ST-elevation myocardial infarction (STEMI) and T2DM who are at high risk of develo­ping cardiac complications during the inpatient treatment by including the sodium-glucose transport protein 2 (SGLT2) inhibitor dapagliflozin in the comprehensive therapy. Materials and methods. The study group consisted of 38 patients with STEMI and T2DM who received dapagliflozin in addition to percutaneous coronary intervention (PCI). The control group included 37 patients with STEMI and T2DM who received only standard protocol treatment after PCI. In addition to general clinical examinations and assessment of quality of life using the EuroQol Group EQ-5D-5L questionnaire (1990), echocardiography was performed to determine general and local myocardial contractility by the Simpson method; plasma levels of glucose, insulin were evaluated, and insulin resistance was determined by the HOMA-IR. Results. Patients with STEMI and T2DM after PCI most often developed reperfusion syndrome with left ventricular failure and rhythm disturbances. Under the influence of standard medical treatment, a significant clinical and functional improvement was observed, but postinfarction remodeling progressed with impaired systolic and diastolic function and the development of heart failure syndrome, as well as treatment-resistant atrial and ventricular fibrillation paroxysms, supraventricular and ventricular extrasystoles, and bundle branch block. In patients of the study group with STEMI and T2DM on the comprehensive treatment with the SGLT2 inhibitor dapagliflozin, a significant decrease in the frequency of rhythm and conduction disturbances was noted on the se­cond day of observation, as well as a decrease in postinfarction left ventricular remodeling, which ultimately manifested in a statistically significant improvement of myocardial contractility (ejection fraction increased by 6.7 %) and a decrease in diastolic dysfunction. There was also a significant decrease in the frequency and severity of reperfusion arrhythmias, which was achieved due to the cardiometabolic effect of the SGLT2 inhibitor dapagliflozin. Conclusions. The inclusion of the SGLT2 inhibitor dapagliflozin in the comprehensive treatment led to a significant improvement in central cardiac hemodynamic parameters and a decrease in the frequency and severity of reperfusion arrhythmias and acute left ventricular failure, which contributed to the improvement in quality of life.

New Onset Dyspnea in a Patient with Pacemaker, What Does the ECG Tracing Show?

Dual chamber pacemakers are programmed to allow for AV synchrony. Whenever a patient with a dual chamber pacemaker with underlying sinus rhythm presents with AV dissociation, the lack of AV synchrony should be questioned. The authors present a case of new onset dyspnea diagnosed as pacemaker syndrome. The diagnosis was initially delayed due to underlying ventricular paced rhythm as misidentified as normal pacemaker behavior. A 69-year-old female with a past medical history of 2:1 atrioventricular block status post dual-chamber pacemaker implant presented with complaints of new onset shortness of breath and dyspnea. The ECG showed a ventricular rate of 66 beats per minute. Pacing spikes were prior to each QRS complex indicating ventricular-paced rhythm with left bundle branch morphology. There were p waves from sinus origin which were completely dissociated from the ventricular paced rhythm. Overall, there was ventricular paced rhythm with underlying AV dissociation. This was initially suspected to be normal pacemaker behavior as there was appropriate ventricular pacing and ventricular capture. Review of the tracing noted AV dissociation, which would be unusual in a patient with underlying sinus rhythm and dual chamber device. Device interrogation noted that device was at end of life and atrial lead was powered down to allow for ventricular pacing. It is important to always question the lack of AV synchrony if patients have dual chamber pacemaker as lack of AV synchrony can cause pacemaker syndrome.

Экстрасистолия у пациентов с синдромом дисплазии соединительной ткани

The ventricular heart rhythm disturbances occurring in individuals with no structural heart abnormality are a pressing issue not only due to their significance, but also due to the lack of clear approaches to treatment of such patients. In actual clinical practice, the physician faces a number of unresolved problems related to both causes and treatment of premature heath beats. This issue requires further research aimed to determine the optimal tactics of management for the specific patient with premature heath beats.

Atrial fibrillation organisation correlates with ventricular response regularity in patients with persistent atrial fibrillation

Abstract Background Atrial fibrillation (AF) is characterised by an irregularly irregular ventricular rhythm. However, the mechanisms by which the regularity of ventricular response is influenced by AF dynamics is yet to be understood. In AF, there is a spectrum of organisation of atrial electrical activity; from organised AF sustained by focal drivers through to disorganised AF sustained by multiple wavelet re-entry. We aimed to investigate whether the ventricular response in AF was associated with the organisation of atrial electrical activity, with the hypothesis that AF organisation correlates with ventricular response regularity. Methods We retrospectively reviewed data from 239 patients with persistent AF undergoing pulmonary vein isolation (PVI). In each patient both before and after ablation, AF organisation and measures of ventricular variability and irregularity were evaluated in 50s segments. Shannon entropy (ShEn) and Sample entropy (SampEn) derived from coronary sinus (CS) atrial electrograms were used to assess AF organisation. RR interval (RRI) metrics derived from the surface ECG were used to determine ventricular variability and irregularity. RRI variability was evaluated using the time-domain measures: normalised mean RRI difference, standard deviation of RRIs (SD RRI), normalised SD RRI, root mean square of successive RRI differences (rMSSD) and percentage of successive RR intervals that differ from each other by more than 50ms (pNN50). RRI irregularity was measured using SampEn and normalised SampEn. Results A significant decrease in atrial ShEn and SampEn was observed following PVI across all CS channels (e.g. SampEn CS 3-4: pre-ablation=0.907±0.512 vs post-ablation=0.790±0.447, p&amp;lt;0.0001). Both ShEn and SampEn from CS atrial electrograms were significantly correlated with the RRI variability and irregularity measures from surface ECG (pNN50, normalised mean RRI difference, normalised SD RRI and normalised SampEn) both pre- and post-ablation (pNN50: r=0.0771, p=0.00838, Figure 1; normalised mean RRI difference: r=0.144, p&amp;lt;0.0001; normalised SD RRI: r=0.175, p&amp;lt;0.0001; normalised SampEn: r=0.168, p&amp;lt;0.0001; correlations with SampEn CS 3-4 pre-ablation shown). Conclusion The reduction in atrial ShEn and SampEn following PVI suggests that an increase in AF organisation occurs with PVI. The significant correlations between atrial entropy and measures of RRI variability and irregularity suggest that AF organisation impacts ventricular response regularity. Therefore, interpretation of the RRI variability and irregularity from the surface ECG may give some insight, non-invasively, into the level of AF organisation.Figure 1

Abstract 15242: The Flipside of Flecainide: A Case of Flecainide Induced Loss of Capture

Introduction: Flecainide is a class 1c anti-arrhythmic agent that slows phase 0 of the fast inward sodium (Na) channels in a rate-dependent fashion leading to decreased conduction velocity in the His-Purkinje and ventricular myocardium. Its high affinity and slow unbinding prolong QRS duration on electrocardiogram (EKG). Partial renal excretion and a narrow therapeutic index of 0.2-1mcg/mL can cause drug toxicity. Case: A 72-year-old woman presented with palpitations and weakness. She had a history of non-ischemic cardiomyopathy, biventricular (BiV) implantable cardioverter defibrillator, frequent premature ventricular contractions on flecainide 100 mg twice a day, and chronic kidney disease. She was hypotensive and with acute kidney injury. EKG showed wide complex ventricular rhythm, QRS duration of 305 ms and intermittent ventricular pacing (Fig.1A), changed since EKG 6 months ago (Fig.1B). Device interrogation revealed normal sensing and impedances but failure to capture from all 3 leads. She had stable lead parameters and appropriate BiV pacing 6 months ago. Chest X ray showed stable lead positions. Flecainide toxicity was suspected, and Na bicarbonate infusion was started. Flecainide level was 2.4mcg/mL (normal &lt;1mcg/mL). She went into an idioventricular rhythm which terminated spontaneously (Fig.1C). After 48 hours of Na bicarbonate infusion, lead capture was noted with narrower QRS (198 ms) (Fig.1D) and on day 6, EKG was back to effective BiV pacing with QRS duration 127 ms (Fig.1E). Discussion: This case highlights the EKG manifestations of flecainide toxicity including QRS widening, sine-wave pattern and loss of pacing capture due to prolonged ventricular refractoriness. It also underscores the reversibility of this condition with prompt treatment using Na bicarbonate. Conclusion: Early recognition and rapid treatment of the cardiac effects of flecainide toxicity is critical in managing a life threatening but reversible medical condition.

Abstract 15372: The Lewis Lead

The Lewis lead is a modified ECG configuration that can enhance the amplitude of the atrial electrical activity and is useful when the atrial activity cannot be discerned in the standard ECG. The configuration involves applying the right arm electrode on the manubrium, left arm electrode to the 5th intercostal space on the right sternal border, left leg electrode over the right lower costal margin and right leg electrode in the standard position. The ECG is then interpreted in lead I and II. Herein we present a case where the Lewis lead aided in the diagnosis of complete heart block with underlying atrial fibrillation. Case Presentation: A 75 year old female with severe tricuspid regurgitation was admitted for tricuspid valve replacement. She had previous paroxysmal atrial fibrillation status post pulmonary vein isolation. The preoperative ECG revealed normal sinus rhythm. Postoperatively, ECG demonstrated a narrow complex ventricular rhythm at 70 beats per minute. No atrial activity could be clearly discerned (Image 1). The epicardial atrial wire placed intraoperatively was not functioning, therefore atrial electrogram could not be obtained. It was unclear from repeat ECGs if there was sinus arrest or atrial fibrillation in the atria. The Lewis lead was then utilized and revealed underlying atrial fibrillation (Image 1); together, this was consistent with atrial fibrillation and complete heart block with a junctional escape rhythm. The rhythm did not recover and there was progressive conduction system disease with widening of the QRS and episodes of severe bradycardia. She underwent pacemaker implantation. Discussion: By utilizing the Lewis lead we were able to establish the atrial rhythm and differentiate between atrial fibrillation and sinus arrest. The Lewis lead can also help narrow the differential for wide complex tachycardia by magnifying the p wave, thus making it easier to detect ventriculoatrial dissociation, a hallmark feature of ventricular tachycardia.

Comparison of diagnostic accuracy of current left bundle branch block and ventricular pacing ECG criteria for detection of occlusion myocardial infarction

BackgroundElectrocardiographic detection of patients with occlusion myocardial infarction (OMI) can be difficult in patients with left bundle branch block (LBBB) or ventricular paced rhythm (VPR) and several ECG criteria for the detection of OMI in LBBB/VPR exist. Most recently, the Barcelona criteria, which includes concordant ST deviation and discordant ST deviation in leads with low R/S amplitudes, showed superior diagnostic accuracy but has not been validated externally. We aimed to describe the diagnostic accuracy of four available ECG criteria for OMI detection in patients with LBBB/VPR at the emergency department. MethodsThe unweighted Sgarbossa criteria, the modified Sgarbossa criteria (MSC), the Barcelona criteria and the Selvester criteria were applied to chest pain patients with LBBB or VPR in a prospectively acquired database from five emergency departments. ResultsIn total, 623 patients were included, among which 441 (71%) had LBBB and 182 (29%) had VPR. Among these, 82 (13%) patients were diagnosed with AMI, and an OMI was identified in 15 (2.4%) cases. Sensitivity/specificity of the original unweighted Sgarbossa criteria were 26.7/86.2%, for MSC 60.0/86.0%, for Barcelona criteria 53.3/82.2%, and for Selvester criteria 46.7/88.3%. In this setting with low prevalence of OMI, positive predictive values were low (Sgarbossa: 4.6%; MSC: 9.4%; Barcelona criteria: 6.9%; Selvester criteria: 9.0%) and negative predictive values were high (all >98.0%). ConclusionsOur results suggests that ECG criteria alone are insufficient in predicting presence of OMI in an ED setting with low prevalence of OMI, and the search for better rapid diagnostic instruments in this setting should continue.

Efficacy of Dapagliflozin According to Heart Rate: A Patient-Level Pooled Analysis of DAPA-HF and DELIVER.

Although elevated resting heart rate (HR) is associated with a higher risk of cardiovascular events in patients with heart failure with reduced ejection fraction in sinus rhythm (SR), the relationship between HR and outcomes among patients with heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction and in those with atrial fibrillation (AF) is uncertain. The aims of this study were to examine the association between baseline HR and outcomes across the range of left ventricular ejection fraction, in patients with and without AF, and evaluate the effect of dapagliflozin according to HR. A patient-level pooled analysis of the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure; heart failure with reduced ejection fraction) and DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure trial; heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction) trials. The primary outcome of each was the composite of worsening heart failure or cardiovascular death. Among patients with SR (n=6401, 64%), the rate of the primary outcome was higher in those with higher HR: 16.8 versus 7.7 per 100 person-years for ≥80 bpm versus <60 bpm. The relationship between HR and risk was steeper in heart failure with reduced ejection fraction versus heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction. HR was not associated with outcomes in patients in AF for either heart failure phenotype. The benefit of dapagliflozin on the primary outcome was consistent across the HR range in both SR (Pinteraction=0.28) and AF (Pinteraction=0.56), for example, for SR <60 bpm, hazard ratio for dapagliflozin versus placebo 0.72 (95% CI, 0.55-0.95); 60 to 69 bpm, 0.78 (0.63-0.97); 70 to 79 bpm, 0.73 (0.59-0.91); ≥80 bpm, 0.77 (0.61-0.97). The benefit was consistent across HR range in both heart failure with reduced ejection fraction and heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction. The risk of worsening heart failure or cardiovascular death increased with increasing baseline HR among patients in SR, but this association was not seen among patients in AF, irrespective of left ventricular ejection fraction. The benefit of dapagliflozin was consistent across HR range, irrespective of left ventricular ejection fraction or rhythm. URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03036124 and NCT03619213.

Knowledge and perception of coronary angiography and coronary angioplasty by physicians involved in the management of cardiovascular emergencies in Togo

Objectives: Interventional cardiology is emerging in Togo. The aim of this study is to assess the knowledge and attitudes regarding coronary angiography and angioplasty of physicians involved in the management of cardiovascular emergencies in Togo. Materials and methods: This was a cross-sectional study that was conducted for three months from January 15 to June 30, 2022 and that focused on doctors involved in the management of cardiovascular emergencies in Togo, who volunteered to participate in the study. Results: We interviewed 150 doctors with an average age of 32.8 5.6 years. Eight (10.7%) physicians reported having no knowledge of coronary angiography. All physicians recognized acute coronary syndromes (ACS) with persistent ST-segment elevation, the positive myocardial ischemia test as an indication of coronary angiography. Indications of coronary angiography, such as ventricular rhythm disorders, unexplained heart failure and stable angina were not well understood by 20 (13.3%), 19 (12.7%) and 9 (6.0%) respectively. All doctors knew that angioplasty could be accompanied by complications, but 48% were unaware of the skin complications of irradiation. The availability of coronary angiography and angioplasty in cardiac practice in Togo was ignored by 23 physicians or 15.3%. Coronary angiography and coronary angioplasty were perceived as very expensive by 70.7% of physicians. The cost of these procedures was a barrier to their prescription among 78 doctors (52. %). Conclusion: Coronary interventional cardiology is performed routinely in Togo. Physicians involved in the management of cardiovascular emergencies have a level of knowledge and attitudes that need to be improved.

Abstract P2027: Chronic β-Adrenergic Receptor Stimulation Exacerbates Left Ventricular Dilation And Myocardial Cell Death In Rgs2 Knockout Mice

Sustained sympathoexciation and increased circulating catecholamine level are hallmarks of congestive heart failure. Elevated catecholamine level promotes a sustained β -adrenergic receptor (βAR) stimulation in the myocardium, altering the balance between cell death and survival via intracellular signaling downstream of G s - and G i/o -class G proteins. Previously, we and others reported that moderation of Gα i activity by regulators of G protein signaling (RGS) 2 and 5 separately is key to maintaining normal ventricular rhythm. Here, using single isogenic wild type (WT), Rgs2 -/- , Rgs5 -/- , and Rgs2/5 double knockout (dbKO) adult male mice with or without systemic isoproterenol infusion, we determined whether a compensatory relationship between RGS2 and RGS5 is cardioprotective and promotes myocardial cell survival during chronic sympathoexcitation. We found that basal heart weight-to-tibia-length (HW/TL) ratio of both Rgs2 and dbKO mice was elevated relative to WT control. Echocardiography revealed left ventricular dilation in all three KO genotypes, as evidenced by increased left ventricular internal diameter and volume. Both Rgs2 -/- and Rgs5-/- mice displayed reduced ejection fraction and fractional shortening. To explore the mechanism mediating the LV dilation, we challenged the mice with chronic βAR stimulation by systemic isoproterenol infusion (ISO, 30 mg/kg/day) for 3 or 14 days via subcutaneous osmotic mini-pumps. ISO infusion substantially increased HW/TL ratio in WT mice after day 3, while HW/TL ratio in Rgs2 -/- and dbKO mice was increased with exacerbated LV dilation. After 14-day ISO infusion, only dbKO mice displayed increased lung weight/TL ratio, indicating a congestive heart failure. Additionally, myocardial tissue from saline treated dbKO mice had a larger number of TUNEL + cells that was further increased by ISO infusion, with extensive interstitial fibrosis as visualized with Masson trichrome staining, and increased expression of heart failure biomarkers Mybpc3 and Tnni3 . Taken together, we conclude that the loss of R gs2, more-so than Rgs5, predisposes to myocardial cell death and rapid progression to dilated cardiomyopathy and heart failure during sustained sympathoexciation and β-adrenergic stimulation.

P-wave asystole after a tetralogy of Fallot correction surgery.

A rarely seen arrhythmia is the p-wave asystole also mentioned ventricular asystole, ventricular standstill, or third-degree atrioventricular block with no ventricular escape rhythm. It is the result of the lack of impulse formation in ventricles (absence of idioventricular automaticity) or the failure of impulse transmission to ventricles (conduction disturbance)(1). As the name implies, the ventricles stop pumping, resulting in no effective cardiac output during the phenomenon. It is a potentially fatal rhythm disorder and need immediate diagnosis and treatment. We planned to present a case of p-wave asystole, which developed after tetralogy of Fallot total correction surgery.

Abnormal electrocardiogram and poor prognosis in heart failure with preserved ejection fraction.

Electrocardiogram (ECG) is generally performed in patients with heart failure with preserved ejection fraction (HFpEF), but the prognostic value of abnormal ECG is not fully understood. We aim to explore the prognostic value of abnormal ECG at baseline in HFpEF using data from the TOPCAT trial. A total of 1736 patients from TOPCAT-Americas were included and divided into normal versus abnormal ECG groups. Survival analyses were performed for the following outcomes: the primary endpoint [a composite of cardiovascular death, heart failure (HF) hospitalization, and aborted cardiac arrest], all-cause death, cardiovascular death, and HF hospitalization. Abnormal ECG was significantly associated with higher risks of the primary endpoint [hazard ratio (HR): 1.480, P = 0.001] and HF hospitalization (HR: 1.400, P = 0.015), and borderline significantly with cardiovascular death (HR: 1.453, P = 0.052) in patients with HFpEF after multivariate adjustment. As for specific ECG abnormalities, bundle branch block was associated with the primary endpoint (HR: 1.278, P = 0.020) and HF hospitalization (HR: 1.333, P = 0.016), whereas atrial fibrillation/flutter was associated with all-cause death (HR: 1.345, P = 0.051) and cardiovascular death (HR: 1.570, P = 0.023), but ventricular paced rhythm, pathological Q waves, and left ventricular hypertrophy were not of prognostic significance. Besides, other unspecific abnormalities together were associated with the primary endpoint (HR: 1.213, P = 0.032). Abnormal ECG at baseline could be associated with poor prognosis in patients with HFpEF. Physicians are encouraged to pay more attention to HFpEF patients who present an abnormal ECG instead of ignoring those obscure abnormalities. Key messages What is already known on this topic Electrocardiogram (ECG) is a basic and easily accessible examination for patients with heart failure with preserved ejection fraction (HFpEF). Some findings from ECG such as frontal QRS-T angle, QTc interval, and the Cornell product have been shown to be associated with the prognosis of HFpEF but these results are from studies with relatively small sample sizes. What this study adds Using data from TOPCAT-Americas, this study found that an overall estimation of abnormal ECG significantly predicted poor prognosis in patients with HFpEF. As for specific abnormalities in ECG, bundle branch block mainly predicted heart failure hospitalization and atrial fibrillation mainly predicted death. How this study might affect research, practice, or policy This study reminds physicians to pay more attention to HFpEF patients who present an abnormal ECG.

Increased Left Atrial Stiffness is Significantly Associated with Paroxysmal Atrial Fibrillation in Diabetic Patients.

Atrial fibrillation (AF) and diabetes mellitus (DM) are common pathogenic diseases. Diabetes is an independent risk factor for AF, and coexisting AF is a risk factor for the diabetic pa-tient's progression. The purpose of this study was to see if two-dimensional-speckle tracking echocardiography (2D-STE) might provide valuable criteria for determining the risk of AF in diabetic patients. This retrospective study compared 30 adult diabetic patients with documented paroxysmal atrial fibrillation (PAF) with 30 age- and sex-matched diabetic patients without PAF. Inclusion criteria were: age ≥18 years, sinus rhythm, diabetes mellitus type 2, and the ability to sign the informed consent. Exclusion criteria included: moderate or severe valvular disease, previous myocardial infarction, left ventricular ejection fraction (LVEF) <50%, congenital heart disease, a history of cardiac surgery, paced atrial or ventricular rhythm, inadequate echocardiography imaging. The medical history, clinical, biochemical data and the results of the transthoracic cardiac ultrasound examination were registered during their evaluation at the outpatients cardiology clinics. The mean age of the patients was 62.5±1.7 years, 60% were men. Diabetic patients who experienced PAF episodes demonstrated significantly impaired left atrial (LA) deformation patterns, with decreased LA strains and increased LA stiffness (p < 0.05). The present study demonstrates that LA strains and LA stiffness are significantly associated with the occurrence of PAF in diabetic patients. As 2D-STE of the LA is more sensitive than routine echocardiographic examination, it should be performed in patients suspected of being suffering from PAF.

The diagnostic role of acceleration time measurement in patients with classical low flow low gradient aortic stenosis with reduced left ventricular ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Low-flow, low-gradient (LF-LG) AS can occur with a reduced or preserved left ventricular ejection fraction (LVEF) and is difficult to diagnose in either case(1). The main challenge is to distinguish between true severe and pseudo-severe stenosis. Dobutamine stress echocardiography (DSE) is recommended for the distinction of stenosis severity and LV flow reserve in classical LF-LG AS(2). Individual dissimilarities can be seen in the DSE results depending on the severity of the AS and LV afterload mismatch and/or on the existence of accompanying cardiomyopathy(3). One-third of the classical LF- LG AS with reduced LVEF patients do not have LV flow reserve (an increase of less than 20% in SV during DSE)(2). This patient group with an indeterminate DSE result has high surgical risk, and additional examinations are always required(4). Purpose The aim of our study was to evaluate the role of Acceleration time (AT), Ejection time (ET), and AT/ET ratio in predicting DSE outcome in classical LF-LG AS patients with reduced EF, and to distinguish between true and pseudo AS to determine the cut-off for AT which can be a useful evalu- ation method in clinical practice. Methods Sixty-seven classical LF-LG AS with reduced LVEF patients who underwent dobutamine stress echocardiography (DSE) were included in the study. Patients with ventricular arrhythmia and pace rhythm, moderate and severe mitral stenosis, severe aortic insufficiency, and paradoxical LF-LG AS patients were excluded. According to DSE results, all patients were divided into two groups; true AS and pseudo-severe AS. Aortic valve calcium score was measured in patients with inconclusive DSE results. AT and other ejection dynamics (ET and AT/ET) were calculated by taking baseline echocardiographic records into account for all patients(1,5). The predictive power of AT and other ejection dynamics were evaluated to estimate true and pseudo-severe AS. Results According to DSE results, out of 67 patients, 44 (65.7%) was diagnosed as true severe AS. There was a statistically significant relation between baseline AT and true AS [adjusted OR 4.47 (95% CI 1.93–10.4), p = 0.001]. The best cutoff value of AT was measured as 100 msec according to the Youden index. This value had a sensitivity value of 77%, specificity value of 87%, positive predictive value of 92%, and a negative predictive value of 67%. Conclusion In conclusion, the biggest difference of our study from the other studies in the literature is that we only included LF-LG AS patients with reduced EF in our study. Additionally, the study assesses the predictive strengths of ejection dynamics, one by one, regarding DSE results, and therefore, assesses role of ejection dynamics role to distinguish true and pseudo severe AS. As a result of our analysis, AT has a diagnos- tic role in the determination of true severe AS. Large-scale studies are needed to be carried out regarding true severe AS among LF LG AS patients with reduced LVEF.

Occam's Razor: Two Arrhythmias in a Single Heart?

Occam's Razor: Two Arrhythmias in a Single Heart?

Electroanatomic mapping system guided His bundle pacemaker implantation: experience of the His bundle registry graz

Abstract Funding Acknowledgements Type of funding sources: None. Background Electric conduction disturbances are very common, however, patients in need for ventricular pacing may suffer from pacing-induced heart failure due to unphysiological pacing by the right ventricular lead. Conducting system pacing allows to overcome this common issue with a more physiologic approach, but real-life procedural data using this technology is scarce. Methods We report a single centre experience of the first 63 consecutive patients being implanted with a His-bundle-based pacemaker 09/2020-11/2022 per 3D-mapping guided implantation due to bradyarrhythmia, or for cardiac resynchronisation therapy in heart failure combined with a left-ventricular lead (HOT-CRT) ± a right ventricular defibrillator lead. The identification of the His-bundle-location was done with a 3D electroanatomic mapping system via an introducing sheath that is provided with electrodes at its tip. Results Mean age was 71 [18;87] years, 18/63 (29%) patients were female, mean baseline LVEF was 46±15%. Baseline ECG was captured before implantation: QRS width was 127±34ms, with typical LBBB in 19/63 (30%), typical RBBB in 5/63 (8%), alternating BBB in two patient (3%) and either no BBB or ventricular escape rhythm in 37/63 (59%). Indications for implantation were AV-block grade II-III in 31/63 (49%), primary prophylactic ICD indication in HFrEF in 18/63 (29%), atrial fibrillation with bradycardic conduction in 8/63 patients (13%), sick-sinus-syndrome in 4/63 (7%) and secondary prophylactic ICD indication in one patient (2%). In 57/63 (90,5%) a primary device was implanted, in 6/63 (9,5%) a pre-existent device was upgraded with a HB lead. Therefore, 23 dual-chamber-pacemaker, 5 single-chamber-pacemaker, 10 single-chamber CRT-P, 17 dual-chamber CRT-P, 4 single-chamber CRT-D, 4 dual-chamber CRT-D were implanted. In 63 patients his bundle pacing was attempted, while in 6/63 (9%) patients outside of this analysis the attempt was not successful, these patients were consecutively implanted with a non-HBP-device and therefor excluded from the further analysis. In the 63 patients included in this analysis with a primary successful pacing at the his-position, 5/63 (8%) his-bundle-leads dislocated within the first 48 hours, leading to a secondary success rate of 92%. There were two post-procedural pneumothorax that needed drainage, no major procedure-related complications occurred. Median skin-to skin procedure time was 111±47 minutes in his-bundle-device-implantation. The paced QRS width at the post-implantation follow up was 113±27ms with a change in QRS width of -15±39ms (+72; -92ms). The mean his-bundle sensing was 5,38±5,6mV and the mean threshold 1,1±0,86V over 1,0±0,5ms (0,4;1,5ms). The proportion of ventricular pacing was 75±36%. Conclusion Electroanatomic-guided His bundle pacing as a new innovative technic for physiological pacing is viable including high implantation success rate as well as electric impact, both regarding QRS width and pacing threshold.